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Seeking Solutions to Peaceful Sleep Sometimes Leads to Special Surgery

11.01.2011

For as long as he could remember, Christian Roth needed a very long time to fall asleep. "You learn to adapt," he said. "I thought I was wired this way and I felt pretty powerless."

He tried all sorts of approaches: no caffeine after 3 pm, no electronics use within an hour of bedtime, over the counter sleep aids, candles and lavender, hot baths, even a pre-sleep shot of whiskey.

Even when he was able to get some sleep, he said "I never felt refreshed, I really had to pace myself at work, and if I wanted to go out at night with friends, I'd have to take a nap in the afternoon."

Going to sleep became something he dreaded, "and nighttime was the longest part of my day," he said.

I really had to pace myself at work... and nighttime was the longest part of my day.

-Christian Roth, patient, Stanford Sleep Medicine Center

The rest of his life was good: He met his wife, Liza, in college. They'd married and almost three years ago, their daughter, Emily, was born. Roth's insomnia and lack of sleep was a challenge. "During the day, he'd be in this fog," Liza said. "It became harder and harder for him to fall asleep." He'd put on some weight over the years and, unusual for someone his age, developed high blood pressure. The snoring his wife had learned to tolerate, despite its progressive worsening, evolved into something else, something frightening. "He'd stop breathing," she said. "There'd be loud snoring then all of a sudden just nothing. Then there would be a big burst of air, like he'd been holding his breath. It didn't dawn on me he had sleep apnea. He was a pretty active guy—a non-drinker and a non-smoker."

Hearing about that breathing stop and subsequent gasp for air pushed Roth to call a doctor. "That's when I took it seriously, and the dominoes started to fall." He went to Stanford's Sleep Medicine Center in Redwood City, just a few miles from his home and the nation's first medical clinic established to specialize in sleep disorders.

Remarkable revelation

From the time Christian Roth was an infant, he had trouble sleeping. By the time he'd reached his 30s, his sleep problems had begun to affect his health and almost every other aspect in his life.

After describing his symptoms to physicians there, he was asked to spend a night in one of its state-of-the-art bedrooms so a more detailed and technical picture of his sleep health could be built, in part through dozens of electrodes attached to his body. The results were striking: Roth was demonstrating the kind of obstructive sleep apnea more typically seen in someone 50 years his senior. His Sleep Center physician, Robson Capasso, MD, board certified in sleep medicine and an otolaryngology surgeon, had found a long list of physical impediments that stacked the odds against Roth ever drawing a fully-functional breath.

His tonsils were obstructively large, his palate was too soft and his septum—the wall that separates one nostril from another—was deviated far beyond normal. His tongue was set far back in his mouth; his jaw was also set back in a way that narrowed his airway. Any one of those conditions would have been a significant barrier to the flow of air in and out of Roth's nose and mouth. His physiology was a veritable basket of bad news that added up to a case of severe sleep apnea whose effects had already reached beyond just feeling sleepy.

Roth's problems with sleep made him one of many millions. Capasso said that one in four middle-aged men suffer from some form of sleep apnea—those moments when our breathing either pauses or becomes shallow, limiting the amount of oxygen coming into the body. That normal out-with-carbon-dioxide and in-with-oxygen balance is disrupted, with serious consequences. The brain needs oxygen to function and an excess of carbon dioxide in the blood derails the respiratory center in the brain. The struggle inside the body to reset itself includes the heart, whose regular rhythm is then altered, triggering another set of physical changes.

The first night he was home after the surgery, I almost couldn't sleep because it was so quiet in the room.

-Liza Roth, wife of Christian

Before Roth's sleep surgery, he created a complicated strategy for sleeping and for managing his energy so he'd have enough at the end of the day to do things with his daughter, Emily.

"Having sleep apnea diagnosed and treated is very important," said Clete Kushida, MD, PhD, Medical Director, Stanford Sleep Medicine Center and Director, Stanford University Center for Human Sleep Research. "It can have profound impacts on the cardiovascular system. There is also evidence that people can have problems with brain function."

Typically, the first step in treatment is the CPAP machine—a continuous positive airway pressure pump that gently pushes air into the nose and down the airway to prevent it from collapsing.

UNCOVERING SLEEP'S MYSTERIES

What is sleep apnea?

Snoring is usually the first sign of sleep apnea. The noise of a snore is made most often when breathing in, which vibrates the soft palate and the uvula, the small piece of tissue that hangs down at the back of the throat. When an obstruction completely blocks airflow, which can last for several seconds, the sleeper will struggle to take a breath, snorting and gasping.

If the snoring is loud enough to wake another person, then sleep apnea is likely to be present as well. The irregular breathing prevents a restorative night of sleep, which causes sleep deprivation and may lead to daytime sleepiness, difficulty with memory, concentration and attention. Sleep apnea is now considered the leading treatable cause of hypertension. It is also a risk factor or causative agent of stroke and heart disease.

Are you at risk for sleep apnea?

Your risk for sleep apnea is higher if you are male, more than 50 years old and have a body mass index greater than 28.

Should you see a doctor?

The Epworth Sleepiness Scale can help you gauge your sleep health. If you score 10 or more on this test, then your sleep health definitely needs attention. You may want to consider talking with your doctor or a sleep specialist.
0 = would never doze or sleep
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping

___ Watching TV
___ Sitting inactive in a public place
___ Being a passenter in a motor vehicle for an hour or more
___ Lying down in the afternoon
___ Sitting and talking to someone
___ Sitting quietly after lunch (no alcohol)
___ Stopped for a few minutes in traffic
___ while driving

Finding a solution

Surgery is not what Capasso suggests as a first option for his typical patient. "Surgery comes with its own side effects and results are not completely predictable," he said. If someone can learn to use the CPAP machine, that can be the easiest solution. For others, their sleep apnea may be caused by their weight; Stanford has a 12-week weight loss program Capasso suggests to patients.

However, if someone young and not substantially overweight has sleep apnea caused by physical abnormalities, and that person has tried and failed with the CPAP, the surgery becomes a more sensible possibility, in some cases even the initial treatment approach.

Capasso straightened Roth's septum, removed his tonsils and reorganized his soft palate tissue. The results were even better than Capasso thought they would be. "The first night he was home after the surgery," Lisa said, "I almost couldn't sleep because it was so quiet in the room. I just kept staring at him to see if he was still breathing."

Roth was back to work two weeks after his surgery. He has seen the benefits of getting enough sleep, and healthy sleep, from the moment he wakes up to when bedtime comes. "It's been pretty remarkable,” he said. "I have plenty of energy; I don't feel deflated by early afternoon. I have more energy with my family when I come home from work. I can run and bike and play volleyball—it's like night and day."

Roth's investigation into his sleep problems prompted his brother to do the same, and physicians found that his four-year-old was already suffering from apnea. He has been treated.

Apnea does have a strong genetic component, but it goes beyond the obvious skull and airway features, Capasso said. "There are researchers here at Stanford who are looking at the genetic role in how you control the muscle strength in your upper airway, to keep it open while you sleep, and how your brain responds to variations in oxygen and carbon dioxide. The whole mechanism of obstructive sleep apnea is very complex."

It's amazing how many things are tied to it--so many symptoms just all went away after my surgery.

-Christian Roth, patient, Stanford Sleep Medicine Center

Researchers are also working on a way to capture sleep on an MRI video. "It's under investigation, but we've had some interesting results," Capasso said.

Innovations in the works

CPAP machines are continually developing, becoming smaller and lighter and more comfortable. Beyond that treatment method, however, are new ideas that give Capasso and his Sleep Center colleagues great hopes for very different options. Stanford is part of a multi-center randomized controlled trial to test a nerve stimulator that would act as a pacemaker for the nerve of the tongue. The device pushes the tongue forward to instigate breathing if it senses that a patient is not breathing well during sleep. The pacemaker would be implanted in the chest, with one silicon wire going up to a nerve in the neck and the other to the rib cage. "We are very excited about that technology," Capasso said.

The best future for the treatment of sleep apnea will be those new technologies combined with methods to better evaluate what treatment will work best for an individual patient, Capasso said. "The important thing is to have all possibilities available."

Roth still marvels at his own history with sleep. "It's amazing how many things are tied to it—so many symptoms just all went away after my surgery." He'd done what so many do—learned to live with it—"until I realized it was life-threatening," he said.

"When Christian mentioned sleep apnea, I looked it up on the Web and read about it and it mentioned all the different health effects," Liza said. "It was an 'aha!' moment."

About Stanford Health Care

Stanford Health Care, located in Palo Alto, California with multiple facilities throughout the region, is internationally renowned for leading edge and coordinated care in cancer, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties and primary care. Stanford Health Care is part of Stanford Medicine, which includes Lucile Packard Children's Hospital Stanford and the Stanford University School of Medicine. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Health Care: Healing humanity through science and compassion, one patient at a time. For more information, visit: StanfordHospital.org.

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Over the years, I've really struggled with getting a good night's sleep, so I'd sleep eight to nine hours, but still feel terrible the next day. There was this fog or a cloud over me.

Liza: I tried to do a lot of different techniques to, you know, make our bedroom more relaxing for him to sleep in. Nothing really worked

Christian: So, it came to the point where, I stopped breathing when I sleep.

Liza: I would hear him snore, and then just all of a sudden, stop, and there would be no noise. And then, probably a few seconds later, you'd hear this loud exhale. Just hearing him stop breathing like that, really scared me.

Christian: The next morning she said, "You need to do something about this."

I went to Stanford for a consultation, and they immediately signed me up for a sleep study. The results weren't good. So, I had a very severe sleep apnea.

Severe sleep apnea means you stop breathing "X" amount of times per hour. So, in my case, I stopped almost every minute.

Dr. Capasso: In a younger gentleman with a higher blood pressure, sleep apnea is something that needs to be investigated.

Patients with moderate to severe Obstruction Sleep Apnea have two to four times

higher chance of having a heart attack or a stroke and around five to seven times more chance of having recurring car accidents because of attention failures.

Christian: So, I went in for a follow-up and they actually used this sophisticated camera to look inside my throat; and it turned out that I have like very severe blockage.

Dr. Capasso: For most adults we start with the CPAP. CPAP is the acronym for Continuous Positive Airway Pressure. Basically, it is a device that you use a mask and it splints the airway open so it stops obstructing during sleep.

Unfortunately, around half of the people, despite all best efforts, cannot use the machine.

Christian: I tried the CPAP machine for about four to five months. I was still unable to sleep through the night.

Dr. Capasso: That's when I saw that, given his age, his body mass index, his anatomic structure, he would be a very good candidate for surgery.

Christian: Dr. Capasso was pretty confident that this would help me out, so the first thing he recommended was to obviously, get the tonsils removed, and then clear up the deviated septum, also, to enlarge my nostrils.

Liza: On surgery day, we were just waiting, waiting for him to come out, and he finally did.

And Dr. Capasso came and spoke to my mother-in-law and I right after. And, you know, the first thing he said was, "When he wakes up, he's going to be in lots of pain." But he said, you know, everything went really well.

Christian: The recovery wasn't too bad, actually.

After I got the splint out of my nostrils, it was just amazing and I was like, "Wow. I didn't know I could breathe like this."

I thought the care at Stanford was topnotch. We know that they are one of the leading facilities in Northern California, so I definitely wanted to take advantage of them. And they took the time to explain everything that was going on. And they were confident that they could beat this. So, that in turn, gave me confidence to follow through.

After the surgery, I had much more endurance; and so, it definitely played a factor in me being able to go on long runs, or you know, play volley ball or soccer.

Liza: The first time I noticed something was different, I actually couldn't sleep because it was so quiet in our room. And I remember just staring at Christian while he was sleeping to see if he was still breathing, because he was so quiet. And, I would like, hold my hand up to his nose just to check. And he was fine, and so, it was just amazing to me that it was so quick. And so, I just knew that, you know, whatever Dr. Capasso did in that surgical room was magic.

Christian: It didn't really sink in until two to three weeks after where I woke up in the morning, I just felt incredible. It was like, "Did I just take sleeping drugs? What happened here?" And like this is my new reality. This is amazing.